ICD-10 Diagnoses Codes of Life Insurance Doom

[DocLeah]

Hello all,

I'm brand new because I'm a doctor and avoid all type of insurance questions like the plague... however, it's a must in my current model of practice. I'm giving a presentation next week to a bunch of docs on neurological disorders and one thing I want to bring to attention is codes we shouldn't use flippantly. We all want to get paid and not get audited, which leaves us liable to losing our entire practices as it's as silly as a Monty Python flick but less enjoyable.

SO, my question is - do YOU know of any red flag code list that would cause our patients to be denied for life insurance (or other insurances?). For instance, "Major depression" is overused. People get really sad and have for centuries; must we label them into being excluded. I used "Obesity, unspecified" and had an insurance company want to know how obese, exactly.

I will code people as I think they should be, but that being said, the icd10 code book is larger than the Bible, so I can choose wisely... or just flippantly label people for life and mess up their lives. Can you help?

 

[somarco]

Don't just limit to life insurance underwriting, but health insurance as well. Even though Obamacare eliminated underwriting for traditional individual health insurance there are still long term care plans, disability and sometimes Medicare supplement plans.

I did find a few codes that probably won't cause any problems.
W55.21 (bitten by a cow)
W61-33 (pecked by a chicken)
Y93-D1 (injured while knitting)
W56-22 (struck by Orca whale, initial encounter)

My personal favorite, V91-07 (burned due to water ski's on fire)
20 bizarre new ICD-10 codes | Medical Economics

 

[scagnt83]

Hello all,

I'm brand new because I'm a doctor and avoid all type of insurance questions like the plague... however, it's a must in my current model of practice. I'm giving a presentation next week to a bunch of docs on neurological disorders and one thing I want to bring to attention is codes we shouldn't use flippantly. We all want to get paid and not get audited, which leaves us liable to losing our entire practices as it's as silly as a Monty Python flick but less enjoyable.

SO, my question is - do YOU know of any red flag code list that would cause our patients to be denied for life insurance (or other insurances?). For instance, "Major depression" is overused. People get really sad and have for centuries; must we label them into being excluded. I used "Obesity, unspecified" and had an insurance company want to know how obese, exactly.

I will code people as I think they should be, but that being said, the icd10 code book is larger than the Bible, so I can choose wisely... or just flippantly label people for life and mess up their lives. Can you help?

The biggest problem that I encounter is ambiguity. "Obesity Unspecified" is an extremely broad description... they could be 6'/300lbs... or they could be 5'/300lbs. If that is all you put with no other description or subsequent folllow-ups and treatments, then they have no clue to what extent the obesity affects that persons health.

I recently had a Long Term Care case declined because of ambiguity in a patients records about their mental health.
While taking pain medication for her back after a car accident, she had some episodes of what she described as her "thinking being hazy". Her doctor noted this in her chart... but he put no context with it at all. Verbally, he told her it was because of the medication and if it continued after she stopped the meds to come back for it.
Problem with all of that is her chart did not mention the suspected cause or the recommended course of action for the ailment. To an Underwriter, that means she is likely to have a mental issue that did not get treatment or further tests. The carrier was not willing to reconsider her until after 12 months and after she had seen the doctor for a cognitive exam.

Fortunately I was able to find a different carrier that would accept her after we gave them a statement from the doctor about the "cognitive issue" that was noted in the chart.


Doctors should ask themselves "would a medical professional who has never met this patient understand specifically what is going on by reading this file?". It is not just important for insurance.... but I would think it would be important for medical purposes too right?


Depression can be another big issue. Everybody gets depressed or down at times due to life/stress/health/etc. But once the doctor labels it as "depression" that suddenly marks them for life. Real clinical depression is often reoccurring and people who are clinically depressed are much more likely to file a disability claim due to mental health.

Also oversubscribing depression meds is a big issue. You have family practitioners who just throw meds at what often seem to be fairly normal mental issues considering the context. And there is no substantial talking or therapy before going with meds. Once a person needs meds the underwriters see something as a much bigger issue.


I cant help with exact codes because that is not something that us agents see on a regular basis in most lines of insurance. But my biggest advice is to be specific. Some general ambiguous statement that could be anywhere between so-so and really bad, is about the worst thing an underwriter can see. They want to know exactly what it is and exactly what was done about it.


Mental issues do not really affect life insurance underwriting too much. Very severe depression with suicidal tendencies is the biggest issue. Drug use would be another issue for life insurance (I guess that would be considered mental/neurological?)

But with Long Term Care and Disability Insurance, mental/cognitive issues are a very big deal. Label people with care and be specific.

 

[yorkriver1]

Thank you DocLeah for caring about this issue. So many clients are surprised to find out their minor (to them) concern was labeled, prescribed, and now is reason for denial or higher rates.

 

[somarco]

Many carriers are underwriting from Rx histories more so than doctor notes. Rx histories easier to get, quicker and less expensive than medical records.

Can't say what is going on but when a doc prescribes 4 med's for HBP and two of them are used for CHF and/or pulmonary edema that person will not get a policy.

I don't know if the doc is not leveling with the patient or the patient/applicant is in denial but the end result is the same.

Carriers maintain lists of drugs that are commonly used for heart conditions, alzheimers/dementia, serious psychiatric issues, cancer, etc and as soon as those drugs show up the application is almost always dead in the water.

Cardiac and circulatory conditions treated with anticoagulants, "water pills" to reduce edema and so forth are the ones that seem to cause a lot of confusion and issues.

 

[Medicine Man]

Consider too that understanding ICD-10 is probably beyond the pay grade of most underwriters. When you pair that with what's fast becoming a general ineptitude you've got a recipe for trouble.

For the longest time I assumed underwriters had extensive medical knowledge, experience and backgrounds, but recently have begun to see otherwise.

I suspect many, if not most, are following tables and scripts without any real understanding of what they're reading and ICD-10 isn't going to make things any easier.

 

[somarco]

Underwriters punch buttons and let the software decide.

And as indicated above, underwriters rarely see or use ICD-10 (or 9) codes. They enter conditions and Rx on the app then compare Rx against reports from companies like Intelliscript. Very little old fashioned underwriting any more.

 

[scagnt83]

Underwriters punch buttons and let the software decide.

And as indicated above, underwriters rarely see or use ICD-10 (or 9) codes. They enter conditions and Rx on the app then compare Rx against reports from companies like Intelliscript. Very little old fashioned underwriting any more.

It all depends on the product really. For individual fully underwritten LTD & LTCI the underwriter most definately is reading the chart. Script check is part of it, but it is a small part of it. LI is getting more lax and more automated, but they still read the charts, script check is just a small part of it.

Now for CI/Accident/Ad&d/Hospitalization plans/STD/& Simplified Issue LI/DI; all of those mainly use script checks and MIB reports.

 

[JurgitaMak]

I did find a few codes that probably won't cause any problems.
W55.21 (bitten by a cow)
W61-33 (pecked by a chicken)
Y93-D1 (injured while knitting)
W56-22 (struck by Orca whale, initial encounter)


Such interesting situations

 

[UW Guy]

Hello all,

I'm brand new because I'm a doctor and avoid all type of insurance questions like the plague... however, it's a must in my current model of practice. I'm giving a presentation next week to a bunch of docs on neurological disorders and one thing I want to bring to attention is codes we shouldn't use flippantly. We all want to get paid and not get audited, which leaves us liable to losing our entire practices as it's as silly as a Monty Python flick but less enjoyable.

SO, my question is - do YOU know of any red flag code list that would cause our patients to be denied for life insurance (or other insurances?). For instance, "Major depression" is overused. People get really sad and have for centuries; must we label them into being excluded. I used "Obesity, unspecified" and had an insurance company want to know how obese, exactly.

I will code people as I think they should be, but that being said, the icd10 code book is larger than the Bible, so I can choose wisely... or just flippantly label people for life and mess up their lives. Can you help?

The coding itself isn't a problem (unless you miscode a kaposi sarcoma when you mean solar lentigo- don't laugh I had a case where it happened) the problems usually come in with badly kept records, specifically with things like tobacco use. In electronic records they are NOTORIOUS for leaving "carry over" notes that will screw your patients way more than ICD coding. At least on the whole you're better than your VA peers who cannot provide narrative to a history to save their lives.

And FYI, ICD codes are available online so they're not over an underwriter's "paygrade". The difference is in carriers that actually train their people and those who lean on requirements like Pharma scans to connect the dots on low face amount policies instead of rooting out exactly what's going on.